DO NOT FILL OUT/DUPLICATE/COPY THIS FORM. JUST DOWNLOAD IT.

PROCEED TO YOUR RESPECTIVE REGION (E.G. R1, R2)

THEN LOOK FOR YOUR SPECIFIC PROVINCE or MUNICIPALITY

Republic of the Philippines

Department of the Interior and Local Government
Monitoring LGU Preparedness Actions for a Tropical Cyclone

LGU Information:
City or Municipality of:

Check the box if "YES" or uncheck if "NO"

LGU Actions Yes / No
1 The LCE is within his/her AOR.
C/MLGOO informed LGU of the weather alert with Proof of
2
Service
Get Organized:
Convened LDRRMC within 24 hours upon receiving a
3
severe weather bulletin 4.1.1.1.
Reviewed LDRRM/Contingency Plans and Hazard Risk
4
Maps
Engaged LHO and/or LESU to ensure the inclusion and
4.1 implementation of descriptive epidemiology and pattern
analyses in the DRRM, and the contingency plans 4.1.1.2.
5 Estimated number of evacuees
Conducted PDRA and prepared appropriate response plan 4.1.1.1
Response plan includes actions ensuring compliance of
6
minimum public heath standards 4.1.1.1
7 Organized Administrative/Logistical Support Team
8 Organized Search, Rescue and Retrieval Teams
9 Organized Security Teams
10 Organized Medical Teams in ECs
11 Organized Clearing Operations Team
12 Organized Monitoring and Reporting Team
13 Activated 24/7 Emergency Operations Center
14 Activated Incident Command System
Conducted inventory of supplies, equipment and stockpile
15
of goods
16 Assessed Evacuation Centers (functionality and safe use)
17 Conducted clearing operations and assessed structures
Placed adequate guide markers at strategic locations for
18 evacuees and operations teams
Alert Communities:
19 Informed Punong Barangays of weather advisory
Disseminated public warnings thru established warning
systems and weather bulletins, especially families in
20 identified danger zones
 (For coastal and island barangays) Warned fisherfolks to
21 take precautionary measures when going out to sea
(For coastal and island barangays) Issued prohibitions for
sea voyage and fishing (at sea, lakes, rivers and other
deep waters) and prevented people to cross any body of
22 water
Advised households to prepare survival kits/ secure roof,
23 wall, power lines
Issued suspension of classes for appropriate levels and
24 suspension of work for private and government offices
Execute Plans:
25 Prepared Evacuation Centers
25.1With hand washing area and adequate drainage 4.1.1.1.
25.2With steady supply of clean water
25.3With sufficient quantities of hand soap
With monitoring mechanism to monitor the proper wearing
25.4
of face masks and maintaining proper physical distancing
With facilities fo proper disposal of disposable face masks
25.5 and infectious wastes (such as PPEs, tissue paper, cotton
balls, disposable syringe, needles, etc.)
26 Conducted pre-emptive/forced evacuation
27 Conducted mass feeding
28 Cancelled travel authorities for SAR and frontline personnel
Repacked and prepositioned food packs and non-food
29 items for evacuees
Dispatched and prepositioned SAR/SRR, Medical, Security
30 and Clearing Operations teams
31 Advised Security Teams to maintain peace and order
32 Secured communication, power and water supply lines
Deployed brgy health workers/volunteers to provide
medical, psycho-social, and spiritual counselling to the
33 evacuees
Coordinated with PNP and BFP for reporting of casualties
34 (dead, missing, injured) and damage to structures, if any
C/MHO coordinated with PNP and funeral parlors to
35 manage dead, if any
DILG MC 2020-125 (COVID-19 related Early Preparedness
Checklist)
Conducted CCCM simulation exercises to determine gaps,
36
and implemented solutions
Assess the structual integrity and capacity of vital facilities,
37
such as: 4.1.1.4.
37.1LIGTAS COVID-19 Centers
37.2Health Centers
37.3Hospitals for COVID-19 cases
Public buildings (public markets, land transportation
37.4
terminals and ports)
37.5Lifelines (power, water, and communication)
Assessed functionality of established Early-Warning
38
Systems (EWS) 4.1.1.6.
 Ensure that family Go Bag/Emergency Balde includes
39 COVID-19 essentials (soap, 70% alcohol, bleach, surgical
or cloth masks, etc) 4.1.1.8.
Engaged into a Mutual Aid Agreements with other LGUs for
sharing of resources, emergency services, use of
40
evacuation centers, community isolation facilities and
others) 4.1.1.9.

Other Preparedness Actions not indicated in the Checklist:

Certified True and Correct:

C/MLGOO
 STATUS OF EVACUATION
Confirmation Slip

This is to certify that the following barangays in the City/Municipality of ____________, Province of ___________ conducted pre-emptive/forced evacuation with details indicated below:

FOR EVACUATION EVACUATION CONDUCTED

Name of Barangay Name/Location of Evacuation Centers Name/Location of Evacuation Centers (Ex. Poblacion
No. of Families No. of Families Date (mm/dd/yyyy)
(Ex. Poblacion Elementary School) Elementary School)

Notes:
1. This Certification has to be signed by the Local Chief Executive. Certified by:
2. This has to be submitted not later than 24 hours before anticipated landfall and updated every 5 hours.
3. DILG Field Officer has to ensure compliance to this requirement.
4. Use additional sheets, if necessary.
Name of Local Chief Executive

Date: